Nail Removal 

Procedure name : Removal of nail plate

Equipment : Ethyl chloride, 25 gauge needle , 10 ml Injection syringe, Local Anaesthetic agent, Sterile gloves, Iodine Solution, Sterile fenestrated drape, Small penrose drain or wide rubber brand , Two small hemostats, Periosteal elevator, Nail splitter, Iris scissors or equivalent, Antibiotic ointement,Sterile dressing, Matricectomy supplies : electrosurgical unit, sharp instrument, or sterile cotton tip applicators, and phenol solution (88%).

Indications

• Partial removal : Onycocryptosis (Ingrowing toenail)
• Complete removal : Onycogryposis (deformed,curved toenail), oncomycosis, chronic/recurrent paronychia,Nail bed biopsy

                                                Ingrown nail (Onychocryptosis) on the
                                                medial margin

Contraindications

• Bleeding disorders : prolonged bleeeding time.
• Active infection ,cellulitis : all active infections should be eradicated before matricectomy to prevent seeding of deeper tissue bone.
• Dysvascular toe; gangrenous toe.

Technique

• Verbal patient consent is obrained,and the correct toe is identified.
• Medication and supplies are prepared on a sterile tray or Mayo stand.
• The toe is washed and prepped with providone-iodine solution ,prepping proximally to the level of the metatarsal head , and a fenestrated drape is applied.
• A digital block is performed.
• Grasp the toe in your nondominant hand and use a periosteal elevator to separate the eponychial fold from the dorsal aspect of the nail plate. 
• Slide the periosteal elevator of small curved hemostat under the nail plate with gentle dorsal pressure,separating the nail matrix from the nail plate.
• If removing only the lateral or medial fourth of the nail (as for onychocryptosis), incise the nail longitudinally with a nail splitter or strong scissors, taking care to avoid lacerating the underlying nail bed
• Grasp the nail with a hemostat; remove the nail plate using gentle traction and elevation.
• Perform matricectomy (ablation of germinal matrix) with electrocautery, a sharp instrument (no 15 scalpel or beaver blade), or topical phenol (88% solution applied to germinal matrix with cotton tipped apllication for 1- 2 minutes.
• Remove the tourniquet.Apply antibiotic ointment and a sterile dressing.

                                

        Technique of Nail removal ; separation of eponycial fold, 

      elevate the nail from the nail bed, perform matricectomy

Special Consideration

• Matricectomy decreases the recurrence rate of onychocryptosis,but slightly increases the infection rate.Patient should be counseled that after matricectomy, the nail will be narrower than before.
• If present, granulation tissue should be debrided back to normal tissue. This will leave a concavity that will gradually fill in over time
• The development of increasing pain, swelling , or drainage suggests postprocedural infection, which usually responds to oral antibiotics. Consider plain radiographs to access for underlying osteomyelitis if drainage and erythema are present. If present,surgical referral shoud be considered.
• After performing complete nail plate removal, adhesions may form between the nail fold and matrix,impairing the growth of a new nail plate. Interposing a part of the old nail(or a piece of packaging foil) in this space for 3 weeks is recomended to prevent the complication.This material should be securely affixed to the underlying matrix with absorbable suture

Patient Instructions 

• The dressing can be removed in 48 to 72 hours ; antibiotic ointment is apllied daily for 2 weeks
• For postprocedural pain, over the counter Ibuprofen and acetaminophen are generally sufficient. A piece of dental floss under the advancing nail edge should be applied for the next few months to prevent recurrence of ingrown toenail

Source

Moore A, Meehan RE: Nail removal. In Miller MD, Hart J, Macknight, J (ed): Essential Orthopaedics, 1st ed. Philadelphia: Saunders Elsevier, 2009, pp 854-856.